Saturday, April 24, 2010

DSM-V: A Brief Conversation With Allen Frances

Having come across his email address I could not resist posing a question, and he honored me with a reply, alas another question. I thought the conversation might deserve public exposure.

My question:

"It has seemed to me that in general DSM criteria from 3 on have been necessary but not sufficient to make a dx. The clinician must make a judgement that the pt is ill, THEN use the DSM to classify that illness.
Would it help to emphasize that fact?"

Before I record Frances' response let me elaborate. Many years ago, during a deposition, an attorney pulled out the DSM and walked me through the criteria for some disorder one by one. I had to admit most if not all seemed to be met, at least at first glance, but I still opined that the patient did not suffer from the disorder. This raised a question I might have thought would have an obvious answer: According to the DSM, if the patient meets all the criteria, does that imply they have the illness? I have looked in vein for an answer. This led me to the conclusion that, especially given the Cautionary Statement at the beginning of the book, the proper way to apply the criteria might involve a trained clinician (not an attorney) first making the judgment that the patient suffers from a mental illness, and referring to the diagnostic criteria only to classify the illness, ie to determine which diagnosis fits best.
It seems to me that inclusion of a clear statement on this issue could improve DSM-V.
I figured if anyone knows the answer it must be Dr. Frances. His response:

"Do you mean by ill that the patient has clinically significant distress or impairment?" 
Gee thanks, doc. I think he may be trying to use this as a teachable moment. I believe this question is beside the point, but of course it is very critical.
"Clinically significant distress or impairment," in my opinion, does not qualify as the definition of a mental disorder. Rather it is a threshold. I find it hard to imagine making a diagnosis of mental disorder in the absence of clinically significant distress or impairment, but I hold out the possibility it might be appropriate in some cases. I'm still wondering why he asks. Maybe he just wants to know whether the process I describe above consists of first determining that there is clinically significant distress or impairment, then applying the criteria. Fair enough.

But that is not what I do. I believe there is more to identification of a diagnositc entity than distress or impairment. A disorder must somehow hold together and have a life of its own. It can't just mean feeling really bad or not functioning 100% when things are going rough for example (or did I just define adjustment disorder?).

The term "clinically significant" bothers me too. Does that just mean the problem was so bad the patient sought professional help, or that someone else thought they should seek professional help?

A lot of this debate struggles with determining just how clear the dividing line between normal and sick should be. We lose if we say everyone is sick all the time, or that everyone has an excuse for doing bad things or failing a responsibility. We also lose if we keep those who need it from accessing treatment.

If Dr. Frances responds again, I will post here.

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